Grand Rounds: Volume 3, Issue 26

Welcome to Grand Rounds

William Osler conducting Grand Rounds
(courtesy of the medical archives at Johns Hopkins University)


It is a privilege to host the current issue of the medical blog Grand Rounds. As an afficionado of medical history, it is remarkable to see this latest incarnation of process that has “evolved from centuries-old practices that trained physicians by means of apprenticeships.” (Mueller et al., Mayo Clin Proc 2003 ). Medical grand rounds have morphed from ward-based teaching or using an illustrative case presented in an auditorium (as illustrated above) to a lecture format. In William Osler’s day, grand rounds took place at the bedside and were lead by master clinicians. It is now uncommon for patients to have anything to do with medical grand rounds. Most of the grand rounds that I have attended have been didactic talks delivered by the more senior members of the faculty or occasionally by a guest speaker. More and more, grand rounds appears to be no more than a weekly lecture series. Grand rounds have been poked at in the medical literature, have been critically analyzed with regard to their utility and cost, and have been entirely revamped at one of the oldest hospitals in the country. More recently, some have recommended looking at grand rounds from a “consumers’ perspective“. Clearly, grand rounds will continue to have an important education and social value, but it appears model will continue to evolve over time.

I recommend Dr. Lawrence Altman’s terrific piece on the changes in grand rounds from the 12.12.06 issue of the New York Times. Interestingly, Altman ends his piece with a anecdote about how humor can occasionally crop up in grand rounds. As an in silico experiment I Googled the phrase “grand rounds humor” and was thrilled to see that nearly every one of the first 30 entries linked to an edition of the medical blog grand rounds. I conclude that we are on the forefront of a revolution on grand roundsmanship, one that blends medicine with humor, thoughtfulness, open-mindedness and inclusiveness.With this as an introduction, I present to you the best of the week’s medical blog entries.


It is unusual to have students present cases at traditional hospital grand rounds, which is exactly why I feel compelled to lead off with the medical student entries this week. Of course, the first entry that I will share with you came to me a good 7-1/2 hours after the deadline. Jeffrey, a medical student at Monash University in Australia, being properly interested in the basics of physiology and neuroscience, contributes an interesting review of a phenomena that I’ve experienced, and I am certain that others have as well: music can motivate you during physical exercise and more importantly, help you build positive associations that will increase your desire to continue exercising in the future. Clearly Apple and Nike have capitalized on electronic positive feedback during exercise.

Jeffrey gets an inadvertant bonus point: while looking for something with which to back a pithy comment about his tardiness, I came across a fascinating and personally relevant study done by Dan Ariely at the Massachusetts Institute of Technology entitled, “Procrastination, Deadlines, and Performance: Self-Control by Precommittment” (click here for .pdf). In this study, the authors, after recognizing that procrastination is a familiar trait and that people sometimes attempt to control their procrastination by setting deadlines for themselves, pose three questions:

(1) Are people willing to self-impose meaningful (i.e., costly) deadlines to overcome procrastination? (2) Are self-imposed deadlines effective in improving task performance? (3) When self-imposing deadlines, do people set them optimally, for maximum performance enhancement? A set of studies examined these issues experimentally, showing that the answer is “yes” to the first two questions, and “no” to the third. People have self-control problems, they recognize them, and they try to control them by self-imposing costly deadlines. These deadlines help people control procrastination, but they are not as effective as some externally imposed deadlines in improving task performance.

Also earning bonus points this week is the remarkable Bertalan Mesko, a medical student at the University of Debrecen, Hungary. I am certain that those of you who read last week’s Grand Rounds, or who regularly read his blog, ScienceRoll, are as impressed as I am with the quality of his writing, the depth of his interest, and his sheer productivity. Clearly, Bertalan has a unique degree of intellectual curiosity and an impressive dedication to genetics. As a result of one of his blog entries on newborn genetic screening, he had the chance to make contact with the mother of a child with medium chain acyl CoA dehydrogenase defect. He shares what he learned of the newborn screening system in the United States.

We received another international medical student entry courtesy of Mexico Medical Student, who studies in one of my favorite places in Mexico, Guadalajara. Enrico is a 2nd year student who has been blogging on-and-off since 2000 and has submitted the fascinating “5/4“. I’ve encountered a couple of physicians in my life who enjoy integrating mathematics into medicine (pun well intended). Enrico’s blending of music, math and medicine deserves recognition for creativity and insight.

Patients and Families

The inclusion of families at grand rounds is probably less common than that of medical students or patients. A Medline search for the phrase “parents AND grand rounds” turned up only three papers, including this fascinating speech given by parents of a NICU child to an audience of physicians at teaching hospital.

This week I was fortunate to receive a number of entries from both patients and families, including one from Moreena, the mother of a child awaiting a 3rd liver transplant. At her blog, The Wait and the Wonder, she writes about the public nature of illness, in particular the isolation in plain sight that occurs when a clearly ill child is out in a public place. She also has written a thoughtful piece in response to some of this blog’s musings about privacy issues in medicine in the age of Google and webcams. Moreena brings up the boundary issues in medicine, but not as the idiom used by physicians and nurses refer to professional boundaries. Instead, Moreena thoughtfully discusses the public/private boundaries with regard to illness:

Trying to figure out how much to reveal, and where to draw the line between the personal and the private in the medical world, is still a delicate subject. I’m guessing that many doctors and nurses have a stronger sense of that boundary, since the nature of their jobs thrusts them into the private world of so many people, and with so little ado. (”Hello. My name is Dr. X. And now it is time to feel up your liver!”) Certainly, I would agree that videotaping the comings and goings of hospital personnel without their permission shouldn’t be allowed, especially since so much that was previously private is now broadcast with little thought.But, in trying to protect privacy and the legal interests of the hospital, I hope that doctors and nurses will remember that the medical life, the details that may seem so squicky and intimate to them, are also just part of everyday life for their patients.

Speaking of “squicky and intimate” details, I received an eyebrow-raising entry from Amy Tenderich who writes Diabetes Mine. Her entry entitled, “Too Sexy for My … Pod?” reminds us that patients who live with internal and external devices still need to get undressed in front of their spouses as part of “every day life”. I’ve been fortunate to not really have to consider whether or not my patients consider their port-a-caths to be “not sexy”. Very fortunate. But clearly for a woman with a wireless, continuous glucose monitor attached to her lower abdomen, this may be an issue.

For more on new technologies in diabetes care, I refer you to Dr. Rima Bishara’s entry on insulin pumps. Dr. Bishara is a relatively new blogger with 15 years under her belt as an internest, and we should welcome her into the fold.

Nurses, Dieticians and Pharmacists

It is much more common, in today’s large medical centers, to see specialized versions of grand rounds, including Nursing Grand Rounds (from my residency alma mater), Palliative Care Grand Rounds, and Pharmacy Grand Rounds, among others. Rather than have all of these exist as separate forum, I’m pleased to use thus edition of the medical blog Grand Rounds as a means to include other health care providers.

In doing so, I want to start with an entry from n=1’s Universal Health blog, which is entitled, “Docs On Nurses: CME is a Must. As the husband of a nurse, I found his/her perspective to be both refreshing and enlightening as well as important and extremely well expressed. N=1 makes an important observation that I have, of course, witnessed and been guilty of but had not, until now,appreciated in this manner:

At any given time, in any given healthcare patient setting, nurses are routinely interrupted more than once per minute. This includes while they are administering medications, while they are validating orders, while they are planning care, while they are teaching, while they are comforting a grieving family, while they are discharge planning, while they are in the middle of a sterile procedure – any time, anywhere. This multitasking capability is difficult and complex to learn and to use on a continual basis.Physicians wouldn’t tolerate that routine interruption to that degree and on that basis. But nurses do, and that’s considered the norm of clinical practice.

N=1 reminds physicians (and everyone else) that nurses are not in pace to be “bacon savers” – an attribute that I’ve ascribed to many a nurse who has kept me from making a mistake – but are equals in the healthcare team. This view is probably more common to my generation of physician than, say, my father’s generation, but is still not universally accepted. I want to highlight this post for both the importance topic and the excellence of the writing. My stethoscope is off to you, N=1.

Nurse Ratched, among others, has been set upon both by JCAHO and by her hospital’s attempt to create new revenue streams. Her post entitled “Bottom Line Therapy” sheds light onto the seemingly endless upward spiral of new programs, metrics, and technologies implemented as the health care system evolves away from simply caring for patients.

In honor of March being National Nutrition Month, Andrea Giancoli who writes The Family Fork, brings us some useful tips for helping patients to evaluate claims made by many of the fad diets that have been popular for the past 30 or 40 years.

On the pharmacy front, the prolific and thought-provoking David E. Williams takes on last week’s Wall Street Journal piece on disparities in the pricing of generic medicines.


Finally, we come to the physicians who have, as usual, provided a wealth of thought provoking entries. Dr. Elmer at Parallel Universes provides what will undoubtedly be one of the first in a slew of posts stimulated by Dr. Jerome Groopman’s latest book, How Doctors Think. Dr. Elmer’s recounting of his colleague’s ‘thinking error’ leads him to opine that we should focus more of our medical education efforts on teaching students how to think as well as what to think about. For those interested in one view of the ‘thinking’ behind medical decision making, I strongly recommend Edmond A. Murphy’s The Logic of Medicine.

RayGunGirl, an intern headed for a career in radiation oncology, shares an extraordinarily personal story that links nicely to Jerome Groopman’s work. One of the problems that Groopman believes leads physicians down the wrong path in their thinking are their biases against certain patients or types of patient. In her entry entitled “Toys in the Attic” she realizes what many seasoned physicians have learned: we all have a lot more in common with our patients that we realize – we just need to be willing to find, admit, or recognize it. Making these types of connections facilitates the empathy that makes for the best physician-patient (or nurse-, pharmacist-, etc.) relationships.

Speaking of interns, surely all of you know that last Thursday was Match Day for nearly 22,000 medical students. For most, it was a fine day, including the author of pumpkin doodle – a fourth year student who matched to her first choice last week, and who I file under “doctors” today on the occasion of her impending graduation and the fact that this is her very first Grand Rounds post. Despite pumpkin doodle’s joy, it should be recognized that there were nearly 28,000 applicants for only 22,000 positions, making for 6,000 unhappy individuals. Dr. Bard Parker at A Chance to Cut is a Chance to Cure reviews the match statistics for the 2007. He finds that family medicine continues to be in decline from the standpoint of filling residency slots with US medical graduates, while radiology and surgery did well. To my surprise, given the stress on the nation’s emergency medicine system, Bard reports Emergency Medicine was this year’s “big winner” according to this one metric.

While the match numbers for internal medicine may be flat, Dr. Val Jones, who writes Dr. Val & The Voice of Reason, has seen interns with the compassion, drive, and determination needed to be tireless advocates for their patients. She describes one such intern in her entry entitled, “Do The Right Thing“:

The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”

Dr. Kenneth Trofatte writes the amusingly titled Fruit of the Womb. His two posts this week on early pregnancy loss (part one and part two) shed light on the far less amusing side of obstetrics and gynecology. It wasn’t until I read Dr. Trofatter’s post that I realized that he has given, and will continue to give, far more bad news about the loss of a child that either I or most pediatric oncologists will. I particuarly appreciated this quote:

The MD after my name means that I am the one responsible for the Morbid Discussion that has to take place to inform a couple that they have a pregnancy that didn’t make it through the first trimester.

We have a couple of other great perspectives on discussions with patients. Representing frustrated this week is Artemis who writes (naturally) The Thoughts of Artemis where she vents her frustration with getting her patients to answer questions:

Why is it so difficult to put together a history? It’s not just patients with memory issues who have a hard time compiling a list — so-called “normal” folks have as much difficulty as well. [I]t’s frustrating to have to spend so much time trying to put together the ‘back story’ when it should be as readily supplied as the list of medications that (some) patients put together.

Representing wistful is the always eloquent Signout, who expresses her regret at missing the opportunity to answer a question for her patient:

“I’m a sick, sad old man,” he said, and was quiet for a while. Through the stethoscope, his silence sounded like the inside of a seashell. Then, foggily, as if from inside the earth, he said, “Is this worth it?”I didn’t know how to answer his question. Looking back, I cheerily ignored it.

Keagirl (who I guess chose her name as a play on Kegel), our friendly urologist who writes Urostream, sounded neither frustrated nor wistful following her encounter with a surly and inappropriate Emergency Department physician. I hope that Dr. Bard (above) is correct because it sounds like Emergency Medicine could use the extra help in order to keep their physicians from acting this poorly to the consulting specialists.

We actually heard from two urologists this week, one of whom works on the cutting edge of surgical technology. In his blog, Thoughts from a Robotic Surgeon, Dr. Domenico Savatta shares some of his practice data with regard to robotic prostatectomies and, in my opinion, correctly implores his fellow surgeons to collect and report accurate data to their patients in order to avoid “guesstimating” and in order to help patients make their own informed decisions.

A number of the physician bloggers took on items in the news this week. Of note is an entry from Dr. Philip Gordon’s Tales from the Womb on the use of recombinant human erythropoietin in cancer patients. Once again we find ourselves in a situation where the marketing, and in this case the strong direct-to-consumer (DTC) marketing, has gotten far ahead of the efficacy data for a drug. As one who has used erythropoietin in some non-malignant hematologic disorders as well as in post-stem cell transplant patients, it is interesting and concerning to read his description of the increasing use of rhEpo in neonatology in the absence of clinical trial data in this population. I also agree with his harsh criticism of DTC ads for these remarkably expensive and specialized drugs. It’s one thing to consider the general populations ability to critically assess their need for a drug like sildenafil. It’s another to expect them to be able to critically assess the utility of recombinant hematopoietic growth factors such as erythropoietin or PEG-filgrastim (Neulasta).

In a similar vein, Grunt Doc addresses the recent FDA warnings regarding the reports of bizarre behavioral effects of the prescription sleep medications and shares a case he observed. I strongly recommend reading through the comments to this post, which are nearly as fascinating and entertaining.

Dr. Anonymous, apparently more concerned with staying awake than going to sleep, reports on the news that the “pick me up” people feel when drinking that first cup of coffee in the morning may have more to do with stopping withdrawal symptoms than with the stimulant effects of caffeine.

Over at the superbly produced and extremely well-written Aetiology we have Dr. Tara Smith’s entry on antibiotic resistant bacteria in the non-human members of the primate order. Her entry was inspired by the recent news, and subsequent blog entries, regarding the use of the 4th-generation cephalosporin cefquinome in cattle. We often think about antibiotic resistance from the point-of-view of humans or domestic animals intended for human consumption. Dr. Smith opens our eyes to the potential for spread of resistant organisms to the farthest corners of the planet. Slipping into the juvenile, I must take a minute to say that her line, “I told you you could learn a lot from studying an animal’s ass!” is will surely share with my gastroenterology colleagues in the future.

The international use of antibiotics was also discussed by Dr. Paul Auerbach, who a surgeon with an appointment in Emergency Medicine at Stanford, who specializes in Wilderness Medicine. I envy Dr. Auerbach’s travels to Everest Base Camp in Nepal. He returns with some good advice on the antibiotics that he would recommend taking with for international travel.

While I prefer to share essays in Grand Rounds, I feel compelled to add Dr. Jon Inarritu’s contribution from his blog, Unbounded Medicine. Dr. Inarritu sends us this video of a public service annoucment regarding anorexia, bulimia, and body dysmorphic disorder.

I want to close with two entries from a source that I would not have discovered had it not been for my hosting this issue of Grand Rounds. Reading these reinforces my believe that we are truly privileged, not just to have our remarkable medical blogging community to share our thoughts with, but that we are also very lucky to be able to do what we do in the field of medicine. Susan Palwick is a volunteer emergency room chaplain who has been constructing a series of sonnets based on her experiences. She sends us The Ed Sonnets: Room 6.2 which is beautiful in both its construction and message. To have this alone would have been enough. But read ing through her blog, Rickety Contrivances of Doing Good, I came across this remarkable entry entitled ‘Chaplain Stress’ in which she provides yet another unique perspective and set of observations on circumstances that I have missed due to the desensitization that accompanies frequent exposure. I can’t pull out any one quote because the entire post should be read. I strongly encourage you to visit this and share in the rich subtext that physicians and nurses can sometimes overlook in the stuggle to handle our busy workloads.


That’s all for this issue of medical blog Grand Rounds. It was a treat to assemble Grand Rounds and I hope that you take away as much from reading it as I did from writing it. My thanks to the bloggers whose entries have been used, and to the bloggers who entries there was enough room for. The next issue will be hosted at Medviews on Tueday, March 27th. My thanks also go out to the talented Dr. Nick Genes for keeping this remarkable tradition alive.

Pediatric Grand Rounds: Volume 1, Issue 24

©2003 Derek Dudek

Welcome to Pediatric Grand Rounds, Volume 1, Issue 24!

It seems that many of the pediatricians are swamped with patient care duties. It could be the tail-end of RSV season, the onset of rotavirus season (depending on where you are), or the ongoing norovirus outbreaks. Whatever the case, this week’s call for grand round submission resulted in more entries from the recipients of pediatric care than from the providers. As always, because the purpose of grand rounds is to broaden one’s perspective, I’ve included equal number of both and also purposefully created the artificial divide of physicians and patients to allow one to compare and contrast the perspectives.


I’ve come to expect discussions regarding immunization to come from my friend Flea. However this week it seems that Dr. Rob at Musings of a Distractible Mind is going to carry that particular torch. In his entry, “I Hate Immunizations” he discusses the non-medical aspects of this fundamental work done by our specialty. His inclusion of the very busy 2007 Recommended Immunization Schedule reminds me of the challenges faced by pediatricians who have so much important work to fit into a 15 minute office visit.

The ever-entertaining Flea offers us “More Notes from the Lunatic Fringe”. Flea must have some special radar for finding people with odd credentials weighing in on subjects such as immunization and shaken-baby syndrome because he manages to bring us the story of Viera Scheibner, a retired micropaleontologist from Bratislava, Slovakia, who fancies herself an expert on vaccines despite the fact that she’s neither a pediatrician, a physician, an immunologist, nor even a biologist. After reading his post and the Wikipedia entry on “Dr.” Scheibner, I think that I agree with Flea’s description of her occupying a place far out on the fringe. I am wondering if Flea’s subscription to the New Yorker is up-to-date. If so, he must have loved the story in this week’s issue on HIV and AIDS deniers and the devastating impact they’re having on the lives of HIV-infected people in South Africa.

In a similar vein, Orac’s post, “The Depths of Antivaccination Lunacy” goes into greater detail about people on the fringes of reality trying to link vaccinations to shaken baby syndrome. Orac’s blog, Respectful Insolence has long been one of my favorites, both for the quality of his writing, the depth of the content, and the “prickliness” with which he takes on the pseudoscience frauds who prey on the fears of others.

The always-resourceful Shinga has introduced to me the pediatrician blogger David Blake, who writes the interestingly-named Mavistown 3.0. Shinga volunteered David’s accounting of a parental malapropism for this week’s grand rounds. Happy that I pulled the correct grammatical term out of some dusty 6th-grade synapse, I googled ‘medical malapropism’ to see what else I could find and came up with a couple of cute cartoons courtesy of Twosheep, a knitting blog. Of note, Twosheep is clearly a science nerd. Intrigued, I dug a little deeper and found a bona fide article from The Journal of Family Practice, entitled (appropriately) “Children’s medical malapropisms”. You can get the radiologists (markedly less funny) perspective on medical malapropisms here (note: links to .pdf file).

Sandy, at Junkfood Science, submitted a number of entries, from which I’ve selected her essay on the safety of cow’s milk and the occasional hysteria around recombinant bovine growth hormone (rBGH). While I’m likely to agree with Sandy on the safety of milk, and her assertion, “… that milk is … a perfectly safe, wholesome and nutritious food for growing children and those who choose to enjoy it,” I am, of late, less convinced that cow’s milk is the best food, or even necessary, for human children, as I’ve detailed in my post, “Not Milk?“. This short piece was inspired by new genetic evidence showing that the lactase gene is the egg, and not the chicken (how’s that for mixed metaphors!) when it comes to digesting lactose.

On the NICU front, Neonatal Doc elicited a whopping 38 comments on his post entitled, “Village” where he discusses one of the core dilemmas in neonatology: who does, or should, shoulder the work of caring for the severely impaired children that are the product of our resuscitating younger and younger pre-term infants? In doing so, he raises important and difficult questions about the ethics of “saving” these remarkably premature newborns.

Clearly, though, there are miraculous saves that take place in the NICU. A couple of weeks ago the major news outlets trumpeted the survival of a 22 week old preemie. Laura, at Adventures in Juggling celebrates the healthy checkup of her ex-24-weeker (and the child’s vaccination experience) in her post entitled, “Doing Shots Mean Mommy Style”.

Shinga sent me well over a dozen different selections this week, and I was a little worried that she had failed to include her own entry. Sure enough, tucked at the bottom of a long e-mail I found a link to her post entitled, “Vaccination versus Faith in Vitamins” Touching, But Insufficient Evidence“. It seems like she’s taken her lumps in the fight that we pediatricians wage to prevent illness in children:

This week, I was told that my stance on vaccinations is proof that I am a fool and a pharma shill which is par for the course. I was informed that it has been proved both that healthy children don’t get childhood illnesses and that if they do, those illnesses strengthen their immune systems.

I’m surprised that she didn’t mention the recent JAMA paper which last week provided additional evidence to support the assertion that the multi-billion dollar vitamin and dietary supplement industry is a drain on world-wide healthcare resources. It never ceases to amaze me how people will gulp down expensive handfuls of vitamins and anti-oxidants for which there is little scientific proof but balk at vaccines for which there is both extensive high-quality scientific evidence and decades of experience. In fact, as this analysis states, there seems to be evidence that consumption of certain anti-oxidant vitamins may actually increase mortality!

On the child advocacy front, Lourdes de Asis, over at Allergy and Asthma Source, takes a break from allergies and asthma to bring us a detailed public service message on household poisons.

Signout, who is three-quarters of the way through her internship year (hang in there, Signout!), hasn’t seen a pediatric patient in a while, but shares with us an experience from a couple of months ago on the pediatric oncology service in her post entitled, “The New Black“. She makes an interesting observation:

Talking about death and dying is the new black–it’s all over medical school curricula, residency program workshops, and newspaper science sections.

I agree – it seems that we are now, finally, talking more about death and dying, and as hard as it is to do so with children, I heartily endorse it. Her use of the phrase “[phenomenon] is the new black” reminds me to share with you an interesting project that documents every instance of the phrase ‘is the new’ encountered from various sources in 2005 (courtesy of MetaFilter).

A pediatric grand rounds wouldn’t be the same without some mention of poop. Thankfully, Clark Bartram, who writes Unintelligent Design, shares with us a Code Brown, and a case of Hirschprung disease in a newborn in his post entitled, “The Not So Normal Newborn Nursery: Poop There It Is …“.

And finally, from the housestaff front comes Vitamin K, MD and her blog, Peds. Not Just for Those With a Foot Fetish. Her entry, “… how do I handle this …?” details her reaching the point in her training where she’s learned enough medicine and science to realize that there are too many instances where things are done to patients despite the evidence. Vitamin K – we feel your pain (for which, the evidence now shows, you should use ibuprofen instead of acetaminophen, courtesy of Medpundit).


This episode of Pediatric Grand Rounds also brings a host of emotions from parents: disappointment, frustration, hopelesslessness. Hmm. Sounds like things have been a lot harder for the parents this week than for the pediatricians.

On the parent side, frustration is the theme for Purple Kangaroo who grapples out loud with the differences between food allergy and dietary intolerance and provides a real-world example of the aphorism, “Ask 12 specialists, get 13 different opinions.” Her heartfelt essay highlights an important phenomena in medicine: the disconnect between physicians, who are experienced in dealing with not-well-understood phenomena, and parents, who find such phenomena disconcerting when they happen to their children.

Moreena, at The Wait and Wonder, highlights the sense of helplessness that parents of critically ill children experience. She does a wonderful job of showing me an entirely different perspective on the advice that I’ve often given to the parents of my patients. I have told the parents of children who have successfully completed their cancer therapy, and who are consumed with worry about relapse, that it is not possible to predict or control relapse. I tell them, from my relatively safe position, that life is full of unknowns. I tell them that I cross the street between the building with my lab and the hospital a half-dozen times a day and never think about the fact that on any one of those occasions, I could be run over by the hospital shuttle. It’s certainly possible, but I’m not going to stop crossing the street just because of the possiblity.

Moreena points out a perspective that I’d not considered:

People with the best intentions have pointed out to me that something bad could happen to any of us, at any time. The idea is that we never know, and usually have no control over bad stuff happening, anyway, so therefore I should just let go of all my constant worrying … Honestly, there is just no way that is ever going to happen …We just don’t worry as much about theoretical dangers. But once we can name the danger; once we know what it looks like, once it takes up space in our lives as a realistic and constantly present concern, then it’s hard not to let the worry take over and taint everything we do.

Thanks, Moreena, for the terrific post and the valuable perspective. You are, without a doubt, my pick for the best of the entries this rounds. Your essay reminded me to also share with everyone a post that I came across from the mother of a young boy with neuroblastoma who writes the blog How Can I Keep From Singing. Her post, “Untitled“, was one of the most heart-wrenching and thoughtful pieces written by a parent I’ve read in a long time. These two posts highlight for me the value of medical blogs – both physician- and patient-authored. What I’ve learned from Moreena and Susan reading these will surely help me to better understand my patient’s parents, and that’s a pretty valuable gift to receive, especially from disembodied words on the internet.

The industrious Shinga forwarded me an entry entitled, “Early days 3” from Whitterer on Autism. Mcewen writes 3 different blogs and in this entry discusses the disappointment of having realized that there were no magic therapies for her child’s speech delay.

On a lighter note, Jen, who writes Unique But Not Alone, a blog that discusses her experience with her daughters’ alpha-1 antitrypsin deficiency, shares some “kid logic” in her post entitled “Ginormous”. This reminded me to share with you an episode of the wonderful radio program This American Life also entitled, “Kid Logic” (note: links to .mp3 file).

Also on a somewhat lighter note (at least I hope it was meant as light), Awesome Mom’s son, in anticipation of getting a shot, decided to induce his own respiratory arrest in the physician’s office. She managed to capture on of her son’s breath holding spells an shares it with us in a post entitled, “How to Surprise Your Pediatrician“. Having done the respiratory arrest thing one this week in the ED, I thank Awesome Mom for pushing my post-traumatic stress button.

Ami Chopine responded to my essay on co-sleeping with her thoughts in favor of co-sleeping.

When I first read Do’C’s post from his blog Autism Street, I truly thought he was a physician or scientist (no offense, Do’C). He writes with the same degree of skepticism and critical thinking that I attribute to Orac and Flea. His entry, “A Hot Cup of Jack Squat” written with fellow blogger Not Mercury dissects yet another pseudoscience essay purporting to link mercury to autism written by an author who is a chemist at the Wisconsin State Laboratory of Hygiene and just so happens to have an autistic child.

Well, that just about wraps up another episode of Pediatric Grand Rounds. I want to thank everyone for their contributions, including those whose couldn’t fit into the current issue. I learned great deal from putting this issue together, and I hope that everyone takes at least one or two pearls away with them. The next issue of Pediatric Grand Rounds is being hosted by Rob over at Musings of a Distractible Mind two weeks from now.

And if you enjoyed this issue of PGR, please return on March 20th as I attempt to take on the original blog Grand Rounds.

Finally, be sure to take a moment and let your fellow bloggers know that the current issue of PGR has been posted so that everyone’s hard work and thoughtful comments can be disseminated along the Internets!

Interesting Question …

There was an interesting question asked of Randy Cohen, who writes The Ethicist in the New York Times Sunday Magazine:

I interview high-school seniors who apply to my alma mater. I routinely Google these students and discovered that one posted information on his blog that reflects poorly on him. May I ask him about the blog? May I mention it to the university? Should it affect the score I give him?

Cohen had an interesting answer:

Put down the mouse and step away from the computer. You should not Google these students in the first place, let alone make your dubious discoveries a factor in college acceptance.

You would not read someone’s old-fashioned pen-and-paper diary without consent; you should regard a blog similarly. Your reading this student’s blog is legal — he posted it voluntarily, and in that sense it is public information — but not every young person grasps this. Many unwisely regard their blogs as at least semiprivate. You should not exploit their youthful folly. Indeed, so befogged are students about online postings — especially to FaceBook, MySpace and the like — that universities commonly devote a portion of freshman orientation to wising them up.

Phillip Burns, who works in the office of student conduct at the University of Nevada, Las Vegas, says, “Many of us in the field have put great time and energy into educating our students on the potential risks involved with online communities and want them to realize how — once posted — that information is out there for pretty much anyone to see and use.” U.N.L.V. itself does not seek out online information in evaluating applicants.

Because such material will not be considered for most students, it is unfair to subject your interviews to this additional scrutiny. What’s more, such online info is unreliable, even when posted by the person himself, as many an Internet dater has learned to her peril. Not every six-foot guy with a head of rich luxuriant hair would be recognized as such. Not in person. Not by his wife. (He’s married? That liar! That tiny, bald liar!)

As to this blog affecting your view of the student, how can it not? You can’t unread it. It’s bound to influence you, and that is part of the problem.

UPDATE: Lublin checked with the university and was told not to ask the student about the blog but to include its URL with his report.

I’m not quite sure that I agree with him. His answer is based, to some extent, on the premise that what people post to their blogs is “… at least semiprivate …” – whatever that means. I’ve come to understand that whatever is posted on the internet is most definitely public. And as such, it is not privileged or protected. The real question is whether or not applicants to a university should have their backgrounds looked into, and if so, how far. Certainly universities look into students backgrounds to a limited extent: they require letters of recommendation, transcripts and test scores. But those items provide only a limited picture. An applicant may choose to solicit recommendations from thre 3 teachers who he has good relationships with, but not the 8 who feel otherwise. If the school or teachers don’t know that the student was arrested for DUI or like to make YouTube videos showing small animals being tortured, then the university may not know the full extent of the applicant they are accepting.

If posting one’s not-so-bright exploits on a blog, or in a video, or as a series of publically available photos reflects poor judgement, shouldn’t universities be allowed to evaluate applicants and taken into account that that applicant may have poor judgement that could cause problems in the future? What does one make of the ability of college applicants to comb through student-written reviews of university faculty available on-line at sites like – reviews that are in no way, shape, or form objective, while colleges shouldn’t Google the names of applicants to look for any serious “red flags”.

The reason I bring this up in this forum is because of an interesting discussion that was held over on Sermo. For those of you not familiar with Sermo, it is an online community of physicians where questions can be asked of the community and, similarly, answered by the community (or a subset thereof). It’s not unlike AskMetaFilter – just medical.

In any case, someone recently posed the following question to Sermo:

Is it ethical to “Google” your patients?

We all experience difficult patients that are not always completly honest with us? I read in some comments on another post that some physicians will preform an informal background check on their patient by “Googling”. I’m not sure if this is productive or ethical. Is it OK to use any resource at our fingertips to dig up information on our patients even without their knowledge? Are there HIPPA implications here?

Needless-to-say, this elicited a number of comments. Also, a “poll” of 135 physician respondants showed that 88% said, “Yes, any information in the public domain is fair game” while 11% said, “No, it is not ethical or legal to search for further information about your patients outside of what is disclosed when taking a history”. Some of the comments were very thought-provoking. I can’t link to the page because Sermo is a member-only community, and I won’t repost the page because I don’t want to violate the privacy of the people who answered. However, I can tell you that a fair number of people answered along the lines of, “I’ve never thought of doing that!”. Here’s an anonymized sample of some of the more interesting responses:

  • “If the patient makes your radar go off and you’re suspicious of something, anything out there is fair. I don’t think there is any HIPAA violation because most of what you would find on Google would have nothing to do with their health.”
  • “Doctors are such funny creatures, we run so afraid of everything. Is is unethical to look at public information about people who are coming to your office? You do not even have to “accept” patients for treatment if you do not choose to. Of course it is OK to look up this information, and there is absolutely nothing about this that violates HIPPA … If you need some information about a patient, then look it up. If you are nosey and gossiping and just plain snooping, then I guess you know the answer. You must look at what is your true motive for researching this information on your patient and determine is it right”
  • “I work part time in an urgent care in [a place with a lot of entertainment personalities], i google people i “kind of recognize” all the time.”
  • “I would consider the Googling of patients highly irregular, unethical and probably a violation of HIPPA. Could you take your patients name and walk to the courthouse and ask a clerk to do a search for you – I think not. Don’t think for a minute that because yuo’re in the internet that no one knows what you’re doing and there is not an electronic fingerprint of the queries you make. Patient – physician confidentiality is the cornerstone of what we do — breaks this and god help us. By the way HIPPA was meant to expedite transfer of medical information — it was not meant as carte blanche to take your patients information and google it.”
  • “If a local newspaper publishes an article about one of our patients, are we prohibited from reading it? If there is a public record of an event that involves one of our patients, are we forbidden from reading or having knowledge of that information? Yes, there is bogus information posted on the web — but there are also numerous valid news sources and community information sources that have just as much validity as our newspapers or our local television newscasts. Is there a difference between seeing information on a computer screen instead of on the page of a newspaper?”
  • “I google patients often, and you would be amazed what I have found. Here are a few examples.A well dressed father brought in his XX year-old son, who had fallen out of a second story window and was in excruciating pain. Father said his son was allergic to everything except oxycontin. I searched the father’s name on the county website and found half a dozen arrests for drug related offenses. I called the narcotics squad of the police department and eventually learned the father had gotten prescriptions for his son from several physicians and emergency departments in the past month … A mother brought in her XX year-old son for treatment of ADHD and unsocialized aggression. The boy’s father had been in prison. There was something that worried me about the way the family acted, so I googled the father. He had escaped from prison and was on “America’s Most Wanted!” I did not say a word. Later that night father was arrested. At 3 AM I heard a knocking on my front door. I figured mother assumed I had turned in the father, so I did not open the door. I later learned mother had left her purse in my office, but I am still glad I didn’t open the door.”
  • “Who said patients have the right to tell us “only what they want us to know”? The whole concept of confidentiality is that they feel safe to tell us EVERYTHING and we will not tell anyone else. Whenever I get the feeling that the patient is not being honest with me I explain “we do not seem to have the rapport that is necessary for a good physician-patient relationship, and therefore…” without being specific. I don’t do tests unless different outcomes will lead to different next steps, and I don’t ask questions unless dfferent answers will lead to different next steps. But since a dishonest or evasive answer can lead to a WRONG next step (just like an erroneous test result) I have to insist on the truth if I am to treat the patient correctly.”
  • “Patients “google” us all the time. But then again, who amongst us has time to “google” patients”

Sometimes you wish the evidence was wrong.

I hate my cell phone.

It’s not because it’s a bad phone. It works fine. The plan I have isn’t too terrible. And, I will admit that it is a valuable tool for my work.

I just hate having to have it.

It’s not unlike the relationship that I have with my pager. I remember the day that I first got a pager – late in my 2nd year of medical school. We were required to rent our own pagers for the start of our 3rd year medical school clerkships. I remember thinking, “How cool. I’ve reached a point in my life where it was important that other people be able to get in touch with me any time of day.” It didn’t take me too long to realize the flaw in my thinking. People higher up the food chain were did not pay for their own electronic leashes. In fact, people at the top of the food chain often didn’t have electronic leashes. They had the privilege of not being accessible 24/7.

I feel the same about my cell phone.

And to think – I was contemplating Blackberry or Treo. I’m glad that I didn’t. Especially after reading Paul Levy’s revelation that he was giving his up. If someone of Paul’s position could do without one, then I can certainly do without.

The one place that I found my cellphone to be helpful was in the hospital. Being tethered to a wall or desk telephone to return a page or call the lab is difficult for an intern, resident or fellow. Housestaff often need to work while walking from ward to ward, or building to building. Especially since the implementation of the 80 hour per week rule – there is a limited amount of time in which to accomplish one’s work. Efficiency is essential, and cell phones help.

However, many hospitals, for many years, have had bans on cell phones in patient care areas. The hospital where I trained for my residency was positively draconian about their rules. You couldn’t use cellphone anywhere in the hospital. In the NICU we had wireless, non-cellular phones. But for the most part you had to use regular wired phones. The rationale for this was that cell phones could interfere with monitoring equipment or other medical equipment. I found this to be incredibly annoying from a housestaff point-of-view, especially because there was no evidence to support this policy. On the flip side, I truly appreciated working in a hospital where every other person didn’t have a phone held to his or her head. While some people (Mrs. Blog, MD, for example) have stellar cellphone manners, many people don’t. I find hospitals to be sonically displeasing environments at baseline – pagers, monitors, alarms, overhead paging, and too many people – and so adding cellphone chatter is throwing gas on the fire. At my previous hospital I took the same joy in telling people that they couldn’t talk on their cell phones that I do in telling people that they couldn’t smoke cigarettes on hospital grounds. Being able to extinguish cell phone conversations somewhat mitigated the fact that I couldn’t tell smokers to stop smoking in the blunt and forthright way that I felt was appropriate for someone smoking outside the door of a children’s hospital.

Yesterday, a report was published in the Mayo Clinic Proceedings clearly showing no interference or interactions between cell phones and medical devices (full text available here). The authors tests 192 medical devices with two different cellular phones (Nokia’s, in case your were curious) and two different phone protocols (one was CDMA and one was GSM). Fortunately they didn’t indicate which cell service they used, so we won’t be seeing annoying Cingular or Verizon ads trumpeting their “hospital safeness”.

The authors concluded:

This study determined that the cellular telephones tested, when used in a normal way, did not cause any interference with the various medical devices present in the patient care areas studied. For institutions that have restricted cellular telephone use, these studies support revision or abolition of the existing policy.

Truth be told – I’m actually a little sad about this, because it means that one of the few cellphone free zones left in the world may be opened to the noise pollution that accompanies unrestricted cell phone use. And I can tell you that there is nothing more frustrating that the collision of a busy medical team and poor cell phone manners. The times I’ve moonlight and walked into rooms to see patients only to have them give me the “just a minute I’m on the phone” hand sign, I’ve walked right out and put their chart at the bottom of the pile. I hate to say it, but if your phone call is more important that discussing your child with a doctor, then your child is probably not that ill.

The authors of the current study recognize this:

If not clinically important adverse effects occur as a result of using cellular telephones in the hospital, then it seems that the advantages this technology brings to institution and patients would be well received. These advantages may be tempered by etiquette and lack of common courtesy by some individuals when using cellular telephones (cellular telephone users talking loudly and obnoxiously, bother other patients and visitors).

I suspect that before too long, hospitals will be like many other places, where cellphone conversations and the bad behavior the accompanies them, is commonplace, and where people are only half-focused on what is going on around them. The potential for cellphone use on airplanes makes me wish that this study had never occurred, and that the evidence-free policy persisted.

Repair Comfort. Decommission War.

This past weekend, when it was markedly warmer here in Boston, the aircraft carrier USS John F. Kennedy was in Boston Harbor prior to being decommissioned (links to lots of photos are available through the most-excellent Boston Blog site Universal Hub).

Now, I’m not big on war, as you may have gathered here. But there is something about seeing a really, really big ship. Maybe it’s just coded for on my Y chromosome. I caught a glimpse of the ship coming into Boston Harbor as I drove home across the Tobin Bridge on Friday morning, and so on Sunday I figured I’d scooter on out there and have a look myself. I wasn’t about to stand in the 5-hour-long line, but I figured I’d snap a picture or two, which I did:


What was much more interesting to me was to see that the U.S.N.S. Comfort, the navy’s “floating hospital” ship, was also here to be worked on. Let me tell you something: the U.S.S. Comfort was more impressive for it’s size. It’s huge. The pictures I took don’t do it justice. The ship is over 270 meters in length (that’s nearly 1/5 of a mile). Here are a couple of snapshots:


There’s a much better photo gallery of the Comfort available here. I rather like the juxtaposition: the hospital ship is in for repairs so that it could continue to serve. The warship was being decommissioned and is going to be mothballed (which I overheard from a navy officer as I was walking to take pictures).

For the love of spiders …


OK. This has nothing to do with medicine, oncology, hematology, or health policy. It’s just something fun. And to some extent it was prompted by an episode of On Point with Tom Ashbrook (WBUR) featuring Greta Binford, an arachnologist, and her adventures with (ugh) spiders. You can listen to the show here and see some of her photos here.

I am moderately arachnophobic, which is one of the (many) reasons that I was not a big fan of living in Cincinnati when I was there for my residency. It was just warm enough there to have plenty of creepy-crawlies. It seems that the climate here in the Northeast makes for a less friendly environment. Either that or the cats have been eating the spiders before we find them.

That being said, I’m not a big fan of killing living organisms. So I was thrilled to hear about the spider and environment-friendly Spider Catcher (pictured above). This gadget apparently allows you to capture spiders without squishing them against the wall.

The ad says it all:

The Spider Catcher is approximately 65cm long which is enough to keep you at a comfortable distance while you pickup and transport the spider or insect to a safe relocation. Perfect for awkward corners or reaching up high, there’s no longer any need to put your back out in your attempt to catch the unwanted pest!The innovative Spider Catcher is capable of catching many different insects, so if you’re plagued by flies or if there’s a dead wasp on your windowsill, the unique bristle head on this fantastic device enables you to gently catch the insect, carefully trap it and then release it outside. In fact, the Spider Catcher is so gentle, you can even use it to capture butterflies and moths without causing any harm to their delicate wings.

Apparently this brilliant device comes from Britain.

Where do you serve the subpoena? The Hall of Justice in Metropolis?

So here I am, trying to do some serious writing tonight, and the table of contents for this month’s Archives of Disease in Childhood shows up in my inbox. Six out of ten times I don’t even bother to read through it, even though I’m an ad hoc reviewer for it, and even though it’s brought to us by the good folks at the British Medical Journal (one of my favorites).

For some reason – maybe I just needed a break – I scanned through the e-mail and barely noticed this one word fly by as I was scrolling quickly through the message:


I did a double-talk in front of the monitor. Superhero? This has to be good. I scrolled back and sure enough, right in front of my eyes, was the title of journal article:

“Superhero-related injuries in paediatrics: a case series”

I thought, “This has to be good. Certainly worth looking up.”

A few minutes later and I have the paper up on my computer, and staring me in the face is its one and only figure:

So, what’s this paper about, you ask? Well, here’s the scoop:

Five cases of serious injuries to children wearing superhero costumes, involving extreme risk-taking behaviour, are presented here. Although children have always displayed behaviour seemingly unwise to the adult eye, the advent of superhero role models can give unrealistic expectations to the child, which may lead to serious injury.The children we saw have all had to contemplate on their way to hospital that they do not in fact possess superpowers. The inbuilt injury protection which some costumes possess is also discussed.

The authors discuss a short case series here. The first, and most detailed, was of a 6-year-old boy who suffered an unwitnessed fall from a 1st floor indow while wearing Spiderman outfit seen above (note the “anatomically correct upper body muscle padding”). In doing so he earned a head bonk, a swollen eye and an injured foot. He had been pretending to be Spiderman and had climbed out of the window. The other four cases were also falls: three kids pretending to be Spiderman, and one pretending to be Superman. As the British authors put it (in that oh-so-British way):

“They were injured after initiating flight without having planned for landing strategies.”

Brilliant. Only the British can make something like this so amusing.

The authors indicate that while they are strong advocates of adventerous play and while they also understand that risk-taking is an integral part of childhood, they caution that parents need to be aware that children may believe that their abilities “have been given a super-boost” with an appropriate costume. They add the following warnings:

Parents whose children dress up as Bob the Builder should understand that hammers and saws are highly likely to be used in play. The parents of Spiderman afficionados should ensure that windows are correctly closed and locked. Superman’s parents may find it easier to encourage their children to wear glasses, and Wonderwoman’s parents may wish to give early fashion advice and not tell lies.

I looked in Medline to see what a search for “superhero” turned up. There are exactly five previous citations that include the word “superhero”. The authors cite what is apparently the seminal paper on the phenomena published in German in 1992 in Praxis der Kinderpsychologie und Kinderpsychiatrie. Entitled, “Dangerous comics – only a fantasy?” this paper considers whether or not the violent fantasy world of comics leads to violence in children. Their work indicates:

Comics with their regressive pull and their independent superhuman heroes represent the archaic world of narcissism unconscious, unwilling to develop and conservative. Violence serves to maintain the original state or regain a harmonious “paradise” … Thus superhero comics are only dangerous for severely disturbed children.

Apparently not.

This being America, and not Britain (which apparently has a better sense of humor about these things), leads me to wonder when we’ll be seeing tags on Spiderman costumes stating: WARNING – THIS COSTUME DOES NOT PROVIDE ACTUAL SUPERPOWERS. DO NOT ATTEMPT TO LEAP FROM BUILDINGS, TREES OR OTHER TALL STRUCTURES. Or when the first lawsuit will come up.

In any case, my point was not so much about the lawsuits, or even the phenomena of children pretending to be Superman and attempting to jump from roof of the garage while wearing a cape made of an old bedsheet. My point is more along the lines of how much fun it is to look at the world with the eyes of a physician or scientist and witness the various oddities of human behavior. Especially with children. It’s the best part of the job. My hat is off to the authors of this fun little paper – first, for taking the time to recognize the patter; second for having the initiative to write it and submit it; and third, for doing it with such style.

You can download and enjoy the paper here.